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Thursday, July 24, 2008

Nclex Exam Questions 3 Saunders

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An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A central venous catheter is inserted into a large vein, typically the internal or external jugulars or the superior vena cava that leads to the right atrium of the heart. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A patient-controlled analgesia pump is the device that allows the client to self-administer pain medication.

In a chemical burn injury, the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves and shoes, are immediately removed and water lavage is instituted before and during the transport to the emergency department. Powdered chemicals are first brushed from the clothing and the skin before lavage is performed.

After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. Although the client may experience anxiety, fear, and pain, these would not be the cause of the client’s confusion and combativeness.

Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Respiratory signs include changes in respiratory rate and the use of accessory muscles for breathing. Abnormal breath sounds and abnormal blood gas values would also be noted. Although the client may experience fear and anxiety and may complain of pain, from the options provided these are not specific to a respiratory injury.

Nursing interventions for the client following an inhalation burn injury includes assessing the respiratory rate every hour, monitoring oxygen saturation levels every hour, and assisting the client in coughing and deep breathing every hour. The head of the bed is elevated to facilitate lung expansion.

In a client with a nursing diagnosis of Deficient Fluid Volume following a burn injury, vital signs should be monitored every hour until the client is hemodynamically stable. The weight should be obtained and recorded daily or twice daily, and I&O measurements should be recorded on an hourly basis. The nurse should monitor the mental status of the client every hour for the first 48 hours.

For a client with impaired tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours, the extremities should be elevated, and the physician should be notified of any changes in pulses, capillary refill, or pain sensation. Pressure dressings and wraps should not be applied around circumferential burns because they could further impair peripheral circulation.

A gallium scan is similar to a bone scan, but an injection of gallium isotope instead of technetium Tc 99m is administered 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to perform. The client must lie still during the procedure. There is no special aftercare.

A fiberglass cast is made of water-activated polyurethane materials and is dry to the touch within minutes, reaching full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.

The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed for the client’s use. Encouraging the client to pull self up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of repositioning by the client.

A client who complains of severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse realigns the client and, if ineffective, then calls the physician. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction without a specific order to do so. Providing pin care is unrelated to the problem as described.

If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth or Kleenex around the edges of the cast is not appropriate.

The use of comfort measures to reduce crying is a simple measure to maintain reduction of a hernia. Coughing and crying and physical activity increase the strain on the hernia. Enemas of any type would increase the strain on the hernia.

A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure. Urine concentration is also not developed well in the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure.

Vasopressin is a synthetic antidiuretic hormone. Administration of this hormone into the bloodstream reduces bleeding. It acts directly on gastrointestinal smooth muscle as a vasoconstrictor. Because it is a vasoconstrictor, it should be infused intravenously via a central line.

Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are possible complications of a Sengstaken-Blakemore tube. Esophageal rupture may also occur and is characterized by the abrupt onset of severe pain. In the event of either of these life threatening emergencies, all three lumens of the tube are cut and the entire tube is removed.

Nausea and vomiting are common presenting symptoms of acute pancreatitis. A hallmark sign is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever is also a common symptom but is usually less than 39° C.

If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should manually ventilate the client with a resuscitation (Ambu) bag and obtain assistance.

The “low exhaled volume” alarm will sound if the client does not receive the preset tidal volume. The causes of this alarm include disconnection of the ventilator circuits from the artificial airway, a leak in the endotracheal or tracheostomy tube cuff, displacement of the endotracheal or tracheostomy tube, and disconnection of any part of the ventilator circuits.

A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarms include excess secretions, mucus plugs, the client biting on the endotracheal tube, kinks in the ventilator circuit, client coughing, gagging, or attempting to talk while fighting the ventilator.

SIMV is one of the methods used for weaning. When this method is used, the respiratory rate is gradually decreased until the client assumes all of the work of breathing independently. This method works exceptionally well when weaning clients from short-term mechanical ventilation, such as for clients who have undergone surgery. The respiratory rate is frequently decreased, usually on an hourly basis, until the client is weaned and is ready for extubation.

The T-piece or Briggs device requires that the client is removed from the mechanical ventilation for a short period of time, usually beginning with a 5-minute period. The ventilator is disconnected and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting.

Tidal volume is the amount of air delivered with each breath on the mechanical ventilator. The respiratory rate is the number of breaths to be delivered by the ventilator. The fraction of inspired oxygen delivered to the client is indicated by the FIO2. A sigh is a breath that has a greater volume than the preset tidal volume.

Prolonged exposure to the sun (including indoor tanning), unusual cold, or other conditions can damage the skin and pose the highest risk for skin disorders.

A skin biopsy is not painless. The most common source of pain during a skin biopsy is the initial local anesthetic, which can produce a burning or stinging sensation.

Sutures are usually removed 7 to 10 days after a skin biopsy. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The physician may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site.

A Wood’s light examination is a painless procedure. Examination of the skin under a Wood’s light is always carried out in a darkened room. This is a noninvasive examination; therefore an informed consent is not required. A hand-held long wavelength ultraviolet light or Wood’s light is used. The skin does not need to be shaved, and a local anesthetic is unnecessary. Areas of blue green or red fluorescence are associated with certain skin infections.

In providing discharge instruction to a client following patch testing, the nurse instructs the client to keep the test sites dry at all times. The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies a loosened patch, this can interfere with accurate interpretation of the allergic reactions. The nurse should reinforce the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application and the final reading is performed 2 to 5 days later.

Nurse suggestion to an older client who complaint of chronic dry skin and episodes of pruritus, The client should avoid applying rubbing alcohol, astringents, or other drying agents to the skin. The client can take one bath or one shower per day for 15 to 20 minutes with warm water and a mild soap, after which the client should apply an emollient to prevent evaporation of water from the hydrated epidermis. A bath using a diluted vinegar solution will further dry the skin. The client should avoid using a dehumidifier because this will further dry room air.

Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

The normal serum amylase level is 60 to 160 Somogyi U/dL in the adult, and slightly higher in the older adult.

Blood glucose samples are obtained by either drawn blood or finger stick with the use of a Glucometer apparatus.

Itching is most often associated with allergy. Photophobia or purulent discharge could be the result of a bacterial or viral infection. Ptosis refers to drooping eyelids and is unrelated to allergy or conjunctivitis. The nurse needs to understand the causative agent to determine whether infection control measures or allergen precautions need to be taken.

The exact cause of Reye’s syndrome is not clear. Many theories of susceptibility exist. Some theories point to the exposure of viral agents or toxins, while others suggest that such exposure merely precipitates the disease in infants and children already at risk. The role of salicylates as a cause is also unclear.

In vaso-occlusive crisis, impaired tissue perfusion to the brain, the kidneys, and the peripheral areas is most threatened. The priority is to correct or minimize the occlusions to prevent necrosis. Treatment includes hydration, oxygenation, and measures to decrease metabolism. A second priority is to address the pain caused by the vaso-occlusion

Preventing the occurrence and the treatment of opportunistic infections are the priority for the child with HIV.

The earliest finding associated with increased ICP would be irritability.

Signs of respiratory distress include the use of accessory muscles; substernal, intercostal, and suprasternal retractions; nasal flaring; and restlessness.

Foods high in sugar lack necessary electrolytes and can create a higher osmotic environment, actually causing more dehydration. Apple juice needs to be limited or avoided, because its high osmolality can cause loose stools. Pedialyte and Infalyte are oral electrolyte and rehydration drinks.

In a client with diarrhea, Rectal temperatures are not taken because the rectal thermometer can stimulate peristalsis and cause more diarrhea.

In mild dehydration, the infant will exhibit a pale skin color. Urine output would be decreased, but anuria would not be present. If anuria were present, physician notification would be necessary. Dry mucous membranes and a flat fontanel would also be noted on assessment of the infant.

Agoraphobia is described as anxiety about being in places or situations from which escape is difficult or might be perceived by the client as embarrassing. Fears typically involve characteristic clusters of situations that include being outside the home alone, being in a crowd or standing in a line, or traveling on a bus, bridge, train, or car.

The therapeutic response is the one that makes the assumption that the client will make his or her own decisions. This approach provides the client with a sense of personal empowerment that will relieve the client’s powerlessness. If the client is still very depressed, decision making is difficult.

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